2.0 Analysis 2.1 Introduction The consequences of this occurrence could have been of a far more serious nature. A critical alarm system was not fitted. Furthermore, a situation which had been developing over a period of time, through wear and tear, had apparently gone unnoticed and/or unheeded. 2.2 The Emergency Stand Fuel Control Lever The vessel's Operations Manual for Diesel Engines RL76 states in part that, if the emergency fuel lever (lever B) is taken out of its position Remote Control and turned to position 0, the pressure in the air control system falls to zero. The air escapes from shut-down servomotor 5.06 and the engine is stopped by interruption of the fuel supply to the injection pumps through the regulating linkage. As no one in the engine-room had touched lever B, it is most likely that it moved by itself from the Remote Control to the 0 position where it was found after the grounding. Shortly before the grounding, the vessel had experienced considerable vibration because of the effect on the propeller of the shallow water through which the vessel was moving. Because the ratchet used to hold the lever at a predetermined setting was worn, the vibration experienced could have been enough to displace the lever to the 0 position. When lever B moved to the 0 position, the engine stopped because of fuel starvation. Because the emergency stand controls override the other control stations, no subsequent movement of these other controls could correct the situation. The reason for the engine failure was not readily apparent to those attempting to restart the engine in the engine control-room because the engine had stalled and all the related alarms were on. It was thus difficult to identify the light which indicated that the engine was being operated from the emergency stand. 2.3 Loss of Directional Control The vessel was fitted with a steerable Kort nozzle instead of the conventional propeller and rudder. Although this type of steering system is more efficient at moderate-to-high engine revolutions, its performance is less efficient at lower revolutions as its efficiency depends on propeller thrust. In this case, propeller thrust was lost when the engine failed, causing the vessel to lose directional stability almost immediately. After the engine failed, no subsequent movement of the helm could steer her back into the channel. 3.0 Conclusions 3.1 Findings The FEDERAL MACKENZIE grounded because of a loss of propulsion and directional control. The main engine stopped because of fuel starvation caused by the emergency stand fuel control lever dislodging from the Remote Control to the 0 position. It is most likely that the lever was dislodged from the Remote Control position by the considerable vibration caused by the vessel navigating at 10 knots with a minimal underkeel clearance. Although the engines were being controlled remotely from the wheel-house, the controls at the emergency stand override all others. Because of the absence of an appropriate warning light on the bridge, the crew members in the wheel-house were not immediately aware of the loss of engine power. It was difficult for those attempting to restart the engine in the engine control-room to identify the warning light which indicated that the engine was being operated from the emergency stand, particularly as a number of alarms relating to the stalled engine were lit. As the steering is governed by the thrust of the propeller in a Kort nozzle, the steering ceased to function when the main engine failed. 3.2 Causes The FEDERAL MACKENZIE grounded because of a loss of propulsion which, in turn, resulted in a loss of steering. The loss of propulsion was caused by the fuel control lever becoming displaced due to the vibration of the vessel while transiting a shallow channel. The Board has no marine safety recommendations to issue at this time.4.0 Safety Action The Board has no marine safety recommendations to issue at this time.